THE STATE LANDSCAPE
Current State -Level GAC Bans
February 2025
Kansas legislature overrides governor’s veto of ban on GAC for minors and prohibition of use of state funds for GAC.
July 2025
Puerto Rico criminalizes provision of GAC to anyone under 21
THE STATE LANDSCAPE
What do the bans (enacted and proposed) do?
• Provider Liability
• Primarily: License Suspension or Revocation
• Also:
• Criminal Charges
• Prohibit Referral/ Aid & Abet
• Extending Time to File Medical Malpractice Claims (SOL)
• New Causes of Action
• Restrictions on State Funds
• No Medicaid/State Funding for Procedures
• Prohibit Use of State Facilities
• Parent Liability
• Child Abuse (not successful so far)
• Child Custody Determinations
GENDER-AFFIRMING CARE
State laws that protect access to gender -affirming care
16 states have laws or policies protecting gender-affirming care for minors
• “Shield” laws vary from state to state, but one core function is to protect providers.
• In California, shield laws protect against certain data uses as well.
THE STATE LANDSCAPE
What do shield laws do? Protects…
• against criminal out-of-state investigations and prosecutions
• against civil liability
• against professional discipline
• when providing telehealth services
• against denial or restriction of facility privileges
• related to professional liability insurance and health plans
• of medical information & other data related to GAC
GENDER-AFFIRMING CARE
State
GENDER-AFFIRMING CARE
LEGAL CHALLENGES TO STATE BANS
Lawsuits have been filed in most states where genderaffirming care bans have been enacted (~17 states out of 26).
Notably, shield laws have been threatened with lawsuits as well.
BASIS
LEGAL CHALLENGES TO GAC BANS
Core Legal Questions:
1. Who has a role in deciding about GAC for minors?
2. If government has a role, what branch of government gets to set policy about GAC?
3. How much deference do the courts owe to that branch of government?
Are bans discriminatory ? If so on what basis?
Do bans infringe on a fundamental right?
Is the discrimination justified?
Who has a role in deciding about GAC for minors?
How much deference do the courts owe to the government decision ?
Do the bans infringe on fundamental rights or liberty interest?
Are bans discriminatory? If so on what basis?
Is the discrimination or infringement justified?
LEGAL CHALLENGES TO STATE BANS
U.S. v. Skrmetti (2025)
• SCOTUS rules that states may ban gender-affirming care for minors (6-3)
• Appeal from Sixth Circuit decision upholding Tennessee and Kentucky bans on puberty blockers and hormone therapy
• Ryan Roe, transgender youth; received testosterone for gender dysphoria
• “Ryan’s gender dysphoria was so severe that he was throwing up before school every day.. getting these medications after a careful consultation process with his doctors and his parents has saved his life. He’s now thriving.”
Skrmetti (June 2025)
• Majority holds that TN ban on gender -affirming care for minors classifies on medical treatment and age
• Discrimination not on the basis of sex, gender identity, or any other protected class Relies on Geduldig : “a State does not trigger heightened constitutional scrutiny by regulating a medical procedure that only one sex can undergo unless the regulation is a mere pretext for invidious sex discrimination”
• This is not a case about parental rights or rights of medical providers.
• Key Empirical Questions
• State of the research on GAC for youth
• Developments in Sweden, Finland, and the UK
GENDER-AFFIRMING CARE
U.S. v. Skrmetti
• Does not require states to ban GAC or prohibit GAC for minors in states without bans
• Does not invalidate shield laws
• Does not reach bans that apply to adults
• Does not reach other laws that exclude transgender people
GENDER-AFFIRMING CARE
U.S. v. Skrmetti
Litigation is still possible on a federal ban
• Federalism
• EPC - animus argument - rational basis
• Parental rights arguments
• Health care provider arguments
BASIS FOR LEGAL CHALLENGES TO GAC BANS
Legal Framework
If government has a role, what branch of government gets to set policy about GAC?
Separation of Powers
Can President override Congress’s allocation of funding to hospitals?
Deference to executive agency actions?
Federalism
Can federal government regulate or criminalize state medical practices?
What restrictions are permissible when the federal government funds state programs?
THE FEDERAL LANDSCAPE
Trump Administration Orders & Actions
• Sex “Redefinition” Order creates new federal definition of sex based on a subset of reproductive characteristics alleged to be determined “at conception”
• Rescinds federal interpretations of the term “sex” that were broader, including those that protected LGBTQ people from discrimination in health care and other settings
• Prohibit the use of federal funds to promote “gender ideology”
• Grants & Research
• Removal of data
GENDER-AFFIRMING CARE
Presidential executive order
• Defines evidence base for gender-affirming care as “junk science”
• Seeks to prohibit facilities from receiving federal funding if they provide GAC
• Directs the AG’s office to pursue claims against providers and support anti-GAC actions by state AGs
• Reaches young people up to 19
THE FEDERAL LANDSCAPE
April 28 Report on Executive Order
• Federal agencies (CMS, SAMHS, etc.) issued memos/letters against GAC for minors
• Department of Defense required health services contractors to discontinue GAC to minors
• OPM has excluded GAC coverage for children of federal employees starting in 2026
• Department of Justice (DOJ) has prepared guidance that crime against female genital mutilation applies to GAC, will work with State Attorneys General
• DOJ has initiated investigations of multiple entities for misleading the public about GAC under the Food, Drug, and Cosmetic Act
• Federally funded research on GAC stopped (&transgender related research more broadly)
• Federal data collection on gender identity has been stopped
THE FEDERAL LANDSCAPE
November 2025 – NPR REPORTING
• A proposed rule that would prohibit federal Medicaid reimbursement for medical care provided to transgender patients younger than age 18.
• A proposed rule prohibits reimbursement through the Children's Health Insurance Program or CHIP for patients under age 19.
• An additional proposed rule would go even further, blocking all Medicaid and Medicare funding for any services at hospitals that provide pediatric gender-affirming care.
• PSLF program for student loan forgiveness closed to orgs providing GAC.
THE FEDERAL LANDSCAPE
• At least two lawsuits have been filed on the GAC EO :
PFLAG v. Trump (youth, parents of trans kids & GLMA) (injunction issued)
Washington v. Trump (states & providers) (injunction issued)
THE FEDERAL LANDSCAPE
Hospitals and clinics in states without state bans, and many with shield laws, stopped providing GAC to minors… at least temporarily. For example, reports from
In response to a recent Williams Institute survey:
• 29% of providers in states without bans reported that they had received threats to their workplace related to the provision of gender-affirming care
• 26% had been personally threatened online
• Over half (55%) of providers have experienced a recent increased demand for care among youth, and many reported long waitlists.
THE FEDERAL LANDSCAPE
Legislation: Budget Reconciliation Act of 2025
Prohibits federal matching funds for “gender transition procedures,” defined to include puberty blockers, hormone treatment and surgery, for persons under age 18 enrolled in Medicaid and CHIP. Federal Medicaid funding prohibited for GAC for minors
GAC would not be an EHB fo r Medicaid expansion plans
Prohibits “coverage of gender transition procedures” as an essential health benefit (EHB) for expansion adult coverage.
• DOJ has drafted legislation creating a private right of action, with a long statute of limitations, for children who have received GAC to sue parents and health care providers
• It is possible a GAC bill will be introduced soon, which could attempt to:
Ban use of other federal funds for gender -affirming care for transgender minors (similar to the “Hyde Amendment”); or
Ban federal funding for facilities that perform gender -affirming care for minors; or
Ban gender -affirming care for transgender minors categorically ; or
Ban all gender -affirming care for trans people, categorically
